Form FA-77 Prior Authorization Request - Targeted Immunomodulators - Nevada

Form FA-77 is a Nevada Department of Health and Human Services form also known as the "Prior Authorization Request - Targeted Immunomodulators". The latest edition of the form was released in November 20, 2017 and is available for digital filing.

Download an up-to-date Form FA-77 in PDF-format down below or look it up on the Nevada Department of Health and Human Services Forms website.

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Prior Authorization Request
Nevada Medicaid – OptumRx
Targeted Immunomodulators
Submit fax request to: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for a targeted immunomodulator.*
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Name:
Strength:
Dosage:
Duration:
Please document the recipient’s diagnosis:
Crohn’s Disease
Ankylosing Spondylitis
Juvenile Rheumatoid Arthritis
Plaque Psoriasis
Psoriatic Arthritis
Juvenile Idiopathic Arthritis
Rheumatoid Arthritis
Other:_______________
CLINICAL INFORMATION
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has had a rheumatology consult. Date:____________ Duration of disease:____________ (if applicable)
The recipient has had a dermatology consult. Date:____________ Duration of disease:____________ (if applicable)
The recipient has fistulizing Crohn’s disease (Crohn’s disease only).
The recipient has mild disease activity.
The recipient has moderate disease activity.
The recipient has high/severe disease activity.
The recipient has at least 5 swollen joints (Juvenile Arthritis only).
The recipient has at least 3 joints with limitations in motion and pain or tenderness (Juvenile Arthritis only).
The recipient does not have moderate to severe heart failure (NYHA class III or IV).
The recipient does not have a history of treated lymphoproliferative disease in the previous 5 years.
The recipient does not have acute or chronic liver disease classified as Child-Pugh class B or C.
The recipient does not have multiple sclerosis or another demyelinating disorder.
The recipient does not have an active infection or history of recurring infections.
The recipient has had a negative tuberculin test prior to initiating requested treatment.
The recipient has had a positive tuberculin test prior to initiating requested treatment.
Treatment with isoniazid was started ≥1 month prior to initiating requested treatment (only if test was positive).
List the medications that were tried and failed for the given diagnosis:
Drug Name
Reason for Failure
Date(s)
__________________________
__________________________________
_____________________
__________________________
__________________________________
_____________________
Additional clinical information (if applicable):
– Prescriber’s signature and date required.
PROVIDER CERTIFICATION
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined
by Nevada Medicaid.
Prescriber’s Signature:
Date:
*Authorization will not be given for the use of more than one biologic at a time (combination therapy).
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-77 11/20/2017 pv07/28/2017
Page 1 of 1
Prior Authorization Request
Nevada Medicaid – OptumRx
Targeted Immunomodulators
Submit fax request to: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for a targeted immunomodulator.*
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Name:
Strength:
Dosage:
Duration:
Please document the recipient’s diagnosis:
Crohn’s Disease
Ankylosing Spondylitis
Juvenile Rheumatoid Arthritis
Plaque Psoriasis
Psoriatic Arthritis
Juvenile Idiopathic Arthritis
Rheumatoid Arthritis
Other:_______________
CLINICAL INFORMATION
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has had a rheumatology consult. Date:____________ Duration of disease:____________ (if applicable)
The recipient has had a dermatology consult. Date:____________ Duration of disease:____________ (if applicable)
The recipient has fistulizing Crohn’s disease (Crohn’s disease only).
The recipient has mild disease activity.
The recipient has moderate disease activity.
The recipient has high/severe disease activity.
The recipient has at least 5 swollen joints (Juvenile Arthritis only).
The recipient has at least 3 joints with limitations in motion and pain or tenderness (Juvenile Arthritis only).
The recipient does not have moderate to severe heart failure (NYHA class III or IV).
The recipient does not have a history of treated lymphoproliferative disease in the previous 5 years.
The recipient does not have acute or chronic liver disease classified as Child-Pugh class B or C.
The recipient does not have multiple sclerosis or another demyelinating disorder.
The recipient does not have an active infection or history of recurring infections.
The recipient has had a negative tuberculin test prior to initiating requested treatment.
The recipient has had a positive tuberculin test prior to initiating requested treatment.
Treatment with isoniazid was started ≥1 month prior to initiating requested treatment (only if test was positive).
List the medications that were tried and failed for the given diagnosis:
Drug Name
Reason for Failure
Date(s)
__________________________
__________________________________
_____________________
__________________________
__________________________________
_____________________
Additional clinical information (if applicable):
– Prescriber’s signature and date required.
PROVIDER CERTIFICATION
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined
by Nevada Medicaid.
Prescriber’s Signature:
Date:
*Authorization will not be given for the use of more than one biologic at a time (combination therapy).
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-77 11/20/2017 pv07/28/2017
Page 1 of 1

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